What is the recommended treatment for shingles?

Treatment of Shingles (Herpes Zoster)

For uncomplicated herpes zoster (shingles), oral antiviral therapy should be initiated within 72 hours of rash onset with valacyclovir 1 gram three times daily for 7 days, famciclovir 500 mg three times daily for 7 days, or acyclovir 800 mg five times daily for 7 days. 1, 2, 3, 4

First-Line Antiviral Therapy

• Antiviral therapy is most effective when started within 72 hours of rash onset 5
• Recommended oral antiviral options include:
  • Valacyclovir: 1 gram three times daily for 7 days 2, 4
  • Famciclovir: 500 mg three times daily for 7 days 3, 6
  • Acyclovir: 800 mg five times daily for 7 days 5, 7
• Valacyclovir and famciclovir are preferred over acyclovir due to better bioavailability and less frequent dosing requirements 4, 6

Special Populations and Severe Disease

• For immunocompromised patients or those with disseminated/invasive herpes zoster:
  • Intravenous acyclovir 5 mg/kg every 8 hours is recommended 8, 1
  • Temporary reduction in immunosuppressive medications should be considered 8
  • Continue treatment until all lesions have scabbed 8

Treatment Duration

• Standard treatment duration is 7 days for immunocompetent patients 2, 4
• Extended therapy beyond 7 days has not shown significant additional benefits 7
• Treatment should continue at least until all lesions have scabbed 8, 1

Management of Pain

• Adequate pain management should be combined with antiviral therapy 6
• Pain control options may include:
  • Non-narcotic analgesics for mild pain
  • Narcotic analgesics for moderate to severe pain
  • Tricyclic antidepressants or anticonvulsants for neuropathic pain 5

Patient Education

• Patients should be advised that lesions are contagious to individuals who have not had chickenpox and should avoid contact with susceptible individuals until lesions have crusted 1
• Patients should be informed that early treatment can reduce the severity and duration of acute symptoms, but may not completely prevent postherpetic neuralgia 5, 7

Common Pitfalls and Caveats

• Delaying treatment beyond 72 hours significantly reduces efficacy, though some benefit may still be observed with later initiation 4
• Adding corticosteroids to antiviral therapy provides only modest benefits in reducing acute pain and does not significantly reduce the incidence of postherpetic neuralgia 7
• Ocular involvement requires prompt referral to an ophthalmologist to prevent serious complications 5
• Topical antiviral therapy alone is not recommended as it is substantially less effective than systemic treatment 9